We strive to make information readily available to your office. We understand that your office is affected by any changes to the contracts that you hold through Mercy Managed Care. In efforts to keep you updated, this section is designed to update you on contract information including: new contracts, contract terminations, rate updates, TPA changes, and miscellaneous other news.

Please be aware that not all rate changes or contract updates below will necessarily pertain to everyone. We are also not able to publish specific rate information online as that data is confidential. Please see the additional resources below that are available to you to confirm specific contract participation.

• Mercy Network LLC providers: If you are participating with Mercy via a contract with Mercy Network LLC (this would include providers in Southwest Missouri,  Northwest Arkansas, Oklahoma and select providers in St. Louis), please reference your online matrix for specific contract participation.
• Mercy PHO providers: If you are contracted with Mercy via the Mercy PHO (this would include the majority of providers in the St. Louis region), please reference your PHO contract and enrollment packet for a listing of the contracts you hold through Mercy.
• Mercy employed/integrated providers in the St. Louis region: Please continue to reference the Managed Care hub on Baggot Street, and the Sharepoint site as your reference for contract participation.
• All other Mercy employed/integrated providers: Please continue to use the Managed Care hub on Baggot Street as your reference for contract participation.

Provider Changes
As a contracted provider, it is important to notify us immediately of changes to your practice such as: a new provider joining the practice, changes in billing information, provider leaving the practice, or adding a new clinic location.  Notification may help avoid claim denials.  Please submit changes by fax 417-820-3821 or email. Please include a W-9 Form if the change involves a new billing address or tax identification number.

Anthem Provider Newsletter – Missouri November 2023

This month’s featured articles:

Digital Tools

• Digital RFAI process improvements

Education and Training

• Practitioners’ rights during credentialing process

Administrative

• Updates to correct coding editing
• 2024 Medicare Advantage service area and benefit updates
• Usage of liability modifiers
• CAA: Maintain your online provider directory information
• Filing digital claims disputes: Transparent and trackable
• Improvements to secure messaging through Availity Essentials

Policy Updates

• Carelon Medical Benefits Management, Inc. updates — November 2023
• Medical Policies and Clinical Guidelines updates — November 2023
• Expansion of Carelon Medical Benefits Management, Inc. programs
• Prior authorization requirement changes effective February 1, 2024 – codes 32274 and 32275
• Expansion of Carelon Medical Benefits Management, Inc. programs, effective April 1, 2024
• Prior authorization requirement changes effective February 1, 2024 – code J1411

Reimbursement Policies

• Reimbursement policy update: Pharmaceutical Waste – Professional and Facility

Federal Employee Program

• FEP^®Specialty Pharmacy prior authorization list
• Federal Employee Program specialty pharmacy prior authorization review

Pharmacy

• Specialty pharmacy updates
• Pharmacy information available on our provider website

Quality Management | Commercial / Medicare Advantage

• HEDIS measurement year 2023 documentation for Childhood Immunization Status (CIS)
• Controlling high blood pressure and HEDIS^®
• Be Antibiotics Aware: Protect your patients
• HEDIS medical record submission made easier with our Remote EMR Access Service
• HEDIS measurement year 2023 documentation for Transitions of Care (TRC)
• Statin therapy end of year best practices

Click on the following link to access the current edition of Cigna Network News.

Cigna Network News 4th Quarter 2023

HealthChoice Network News – Fall 2023

In this issue

• Outpatient tier 1 and 2 claims billing with J1 codes
• Modifiers 26 and TC
• Smart Logic utilization management
• HealthChoice Connect to be decommissioned
• Certification requests
• New contracting self-service portal
• Optum iEDI for direct data entry of claims
• Faxes no longer accepted
• MS-DRG and MS-DRG LTCH Fee Schedules: Version 41 updates
• Fee schedule updates
• HealthChoice contact information

We routinely review our coverage, reimbursement, and administrative policies for potential updates.

As a result of a recent review, we have updated the Preventive Care Services Administrative Policy (A004) to include International Classification of Diseases, 10th Revision (ICD-10) diagnosis code Z29.81: Encounter for human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP).

What this means

Effective for dates of service on or after October 1, 2023, ICD-10 code Z29.81 should be used when submitting claims for encounters for HIV PrEP services.

In accordance with the Affordable Care Act, we will cover these services without a cost share.

Additional information

For additional guidance, view the Preventive Care Services Administrative Policy (A004).

American Specialty Health^® (ASH) now manages the medical necessity review program for Cigna Healthcare–contracted providers who render physical therapy (PT) and occupational therapy (OT) services for customers with Cigna Healthcare commercial and Individual & Family Plans in certain ASH-managed markets.

This policy update only applies to PT/OT services performed in a provider’s office; it does not apply to those performed in an outpatient hospital setting.

What this means for you

PT and OT services that require a medical necessity review can be submitted either preservice or post-service. Submission of the clinical treatment plan is typically not required until after the patient’s fifth visit.

 How to submit review requests

There are three ways to submit medical necessity review requests:

• ASHLink website: ASHLink.com.
• Fax: 877.248.2746.
• Mail: PO Box 509077, San Diego, California 92150.

Additional information

To ensure a timely review, requests should include the clinical treatment plan, necessary clinical information, and progress documentation.

ASH clinicians will review requests using evidence-based medicine and Cigna Healthcare coverage guidelines to determine medical necessity. Following the review, ASH will issue a determination to the requesting provider and Cigna Healthcare customer.

Coverage guidelines

The PT and OT coverage guidelines are available on the Cigna for Health Care Professionals website (CignaforHCP.com).

Learn more

Additional information is available on ASHLink.com. If you have questions, contact the ASH customer service department at 800.972.4226 (option 2).

Effective 01/01/2024 FedEx employees will be moving to the UHC Surest Plan.  This plan accesses the UHC Choice Plus network which Mercy is contracted with Ministry wide.

The link below will take you to the announcement from UHC and contains general information on the change.  You will also find additional links on the announcement that will take you to the UHC website for more information on Surest.

UHC FedEx Announcement

This link is for a webinar session offered by UHC that will provide additional information on Surest and FedEx.  The webinar is scheduled for 10/12/2023 at 12:00 pm CST.

Webinar: Get to Know Surest| Surest health plan

If you have any issues registering for the webinar, please contact the Surest team at

Cigna MA – Medicare_AcuteHistorySequela_Flyer

Cigna Healthcare is committed to providing you with resources and support to ensure more accurate coding and documentation of chronic conditions.

To that end, we developed a best practices flyer that reviews the documentation and International Classification of Diseases, Tenth Revision, Clinical Modification coding as acute, history, or sequela. Examples are provided for myocardial infarction (MI), cancer, and stroke.

Why it matters

Employing best practices and adhering to Centers for Medicare & Medicaid Services (CMS) guidelines for documentation and coding of chronic conditions can help enhance the quality of patient care.

Your next steps

For your convenience, we have attached the best practices flyer. Additional documentation and coding resources are available on the Cigna Healthcare for Medicare Providers website (medicareproviders.cigna.com > Provider Education > Documentation and Coding Resources).

Cigna MA – Authorizations Changes 100123

As you know, one of our goals is to keep patients safe, while improving health outcomes and making care more affordable. One of the ways we do that is through prior authorization, which helps to ensure patient health, safety, and affordability by adhering to evidence-based standards of care.

We update prior authorization requirements on a quarterly basis to align with program or CPT and HCPCS code changes, as well as industry standards. Effective for dates of service on or after October 1, 2023, we removed over 460 codes and added 14 codes to the prior authorization requirements list.

Accessing a list of services that require prior authorization

• Review the list of codes and services that were recently changed on the prior authorization requirements list.
• View the complete list of services that require prior authorization of coverage for Medicare Advantage customers by visiting MedicareProviders.Cigna.com > Prior Authorization Requirements > See Current Requirements.

Cigna Reimbursement Update – COVID-19 Laboratory Services 122123

Guidelines to add 21 COVID-19 laboratory service codes. These services will be  administratively denied when administered at a frequency greater than the medically unlikely edits set by CMS.

Denials will affect the claim line only and include administrative appeal rights. This update is effective for dates of service on or after December 21, 2023.

Anthem Provider Newsletter – Missouri October 2023

This month’s featured articles:

Administrative 

• Enhanced outpatient facility editing for National Correct Coding Initiative: Medically Unlikely Edits (MUEs) 
• National Accounts 2024 Pre-certification list
• CAA:Maintain your online provider directory information

Digital Tools

• A way to help lower-income patients pay for internet service
• Introducing Claims Status enhancements for claim inquiries
• Availity: Medicare provider-facing talking points and FAQ
• Personalized Match Phase 1
• Availity PDM application is now the intake channel for all demographic change requests, including roster uploads

Education and Training

• New website for cancer caregivers

Webinars

• Required training – Model of Care
• You’re invited: Thriving, not just surviving: Youth mental health in today’s world
• Looking to earn CME credits? Check out the CME Engagement Hub!

Policy Updates

• Clinical Criteriaupdates – June 2023

Medical Policy & Clinical Guidelines

• Transition to Carelon Medical Benefits Management, Inc. site of care guidelines
• Medical Policiesand Clinical Guidelines updates 

Reimbursement Policies

• Reimbursement policy update: After-Hours, Emergency, and Miscellaneous E/M Services – Professional
• Genetic Tests: Once per Lifetime 

Pharmacy

• Specialty pharmacy updates — October 2023
• Medicare Part B precert expansion: Adstiladrin, Altuviiio, Idacio, Lamzede, Lunsumio, Rebyota, Signifor LAR, Syfovre, and Vivimusta
• Medicare Part B precert expansion: Elfabrio, Epkinly, Qalsody, Vyjuvek, and Zynyz